Complaint Form

REPUBLIC OF SOUTH AFRICA

SMALL CLAIMS COURT

NB: 1. Please type or print.

2. Please attach copies of the documents (contracts, receipts, etc.) upon which the claim is based.
3. Hand this form to the Clerk of the Court when fully completed.

A. PARTICULARS OF PLAINTIFF

Full Names ……………………………………………………………………………………………………………………………..

Residential Address Work Address
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Postal Address ………………………………………………………………………………………………….. Code ……………….

Telephone Number: (H) ( ……... ) …………………………………. (W) ( ……... ) ………………………………….

If plaintiff is a minor, age ………………………….… years

Name and address of parent or guardian of minor ………………………………………………………………………………….

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B. PARTICULARS OF DEFENDANT

Full Names ……………………………………………………………………………………………………………………………..

Residential Address Work Address
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Postal Address ………………………………………………………………………………………………….. Code ……………….

Telephone Number: (H) ( ……... ) …………………………………. (W) ( ……... ) ………………………………….

Department of Justice and Constitutional Development

 Complaint Form

Please indicate the main aspects of your claim point-by-point and provide names and dates, where possible and
applicable. Also indicate the current state of affairs. Indicate what steps you have taken to resolve the problem. Please
avoid mere references to “attached correspondence”. Please also avoid giving a detailed exposition of the history of the
matter.

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PLAINTIFF’S SIGNATURE DATE

2
Department of Justice and Constitutional Development